Sex in the U.S.: Survey Finds 'Enormous Diversity'

Americans -- young, old, and in-between -- have varied and diverse sexual behaviors, according to a nationally representative study.

by Michael Smith Michael Smith North American Correspondent, MedPage Today
October 04, 2010

Action Points

Discuss with patients that data from a recent study indicate that Americans of all ages have varied and diverse sexual practices.

Discuss with patients that data from a recent study indicate that in women in general tended to report more pain, less pleasure, less arousal, and fewer orgasms.

Americans -- young, old, and in-between -- have varied and diverse sexual behaviors, according to a nationally representative study.

"We found an enormous diversity in the sexual repertoires of U.S. adults," said Debra Herbenick, PhD, of Indiana University in Bloomington. "Adult men and women rarely engage in just one sex act when they have sex."

Indeed, the survey found 41 different combinations of sex acts reported by nearly 6,000 participants, Herbenick and colleagues at Indiana University reported in a supplement to the Journal of Sexual Medicine.

"What it means to have sex can vary greatly from one person to the next," Herbenick told reporters during a telephone press conference in advance of publication of nine papers drawing on data collected by the so-called National Survey of Sexual Health and Behavior.

The journal also includes commentary on the studies from former Surgeon General Joycelyn Elders, MD, and from Kevin Fenton, MD, PhD, of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

The survey, conducted by Indiana University's Center for Sexual Health Promotion, is the first nationally representative survey of sexual behavior in the U.S. since 1992, according to Michael Reece, PhD, director of the center and lead author of several papers in the volume.

It is the "most comprehensive study" of its type, he told reporters, and the first to include Americans as young as 14 and as old as 94.

Aside from the diversity of sexual behavior, the researchers reported a range of other findings:

Condoms are used in one of four acts of vaginal intercourse and the proportion goes up to one in three if the analysis is restricted to singles.

About 85% of men report that their partner had an orgasm at the most recent sexual event, but only 64% of women report they had an orgasm at their most recent sexual event.

One the other hand, about 30% of women report some pain at their last sex act, compared with about 5% of men.

At any given time, most U.S. adolescents are not engaging in any partnered sexual behavior. But when they do have vaginal intercourse -- and the proportions rise with age -- four of five teens will use a condom.

The studies were sponsored by Church and Dwight, which makes Trojan brand condoms.

The researchers said the company had some say in the design of the study -- especially the format of questions about condom use -- but played no role in analysis of the data or writing of the papers.

"They never ask us to change things, they don't ask us to hide data," Herbenick said.

Pressed by reporters, Reece said that there is no scientifically established way to ask questions about condom use. For instance, he said, some studies ask about the percentage of times condoms are used, while others ask about use during the most recent sexual events or series of events.

He said the study team chose to ask about condom use in the past 10 sexual events -- a widely used measure, he said -- as a result of consultation with scientists at Church and Dwight, who have used similar measures in their own work.

"We made an effort to use measures that have been used in the past, validated by others, and would be of use to the scientific community," Reece said.

The condom data seem unlikely to be controversial, for the most part. They show:

Condom use fell with age and was higher among adolescents than adults.

Among adults, it was highest among unmarried adults (46.7% of past 10 events), and higher among black and Hispanic individuals (30.9% and 25.4% of past 10 events, respectively) than other racial groups.

Condom use reported by men during their past 10 vaginal intercourse events was 21.5%, compared with 18.4% reported by women, and similar to rates reported during the most recent such event -- 24.7% and 21.8%, respectively.

Reported condom use in the past 10 events of anal intercourse was 25.8% among men and 13.2% among women and similar proportions were reported for the most recent event -- 26.5% for insertive men, 44.1% for receptive men, and 10.8% for women.

The data on adolescents reveals a complex picture, but in general the kids are all right, according to Dennis Fortenberry, MD, of Indiana University's medical school.

The study included 820 teens, ages 14 through 17, who were asked (with parental consent) most of the same questions posed to adults, although the wording was often modified to match adolescent vocabulary.

Fortenberry said teens engage in the same wide variety of sexual behaviors as do their elders, but the pattern is not static -- younger teens are less active and less adventurous than older adolescents, but the frequency and diversity of activity rises sharply with age.

For instance, Fortenberry said, 14% of 14-year-old males reported any kind of sexual interaction with a partner in the previous three months. Among 17-year-old males, the proportion was 40%, he said.

For all teens in the study, regardless of age, the most common sexual activity was solo masturbation, with a lifetime prevalence of 80% for males and 48% for females.

The lifetime prevalence of vaginal intercourse increased with each year of age for both adolescent men and women -- from 2.2% for boys and 12.2% for girls at age 14 to 40% and 31%, respectively, among the 17-year-olds.

But having initiated sex doesn't mean constant sex, Fortenberry said. In all age groups and both sexes, the rate of vaginal intercourse in the past 90 days was lower than the lifetime prevalence.

One implication of the findings is that sexual education messages should be "tailored" so they focus on both experienced and sexually-naive adolescents, Fortenberry said. "A 14-year-old sexually is not the same as a 17-year-old," he said.

The data also have heartening news -- teens are taking care of their sexual health, Fortenberry and colleagues found.

While the majority of teens are not having partnered sex, those who do overwhelmingly use condoms -- adolescent males reported using condoms for 79.1% of the past 10 vaginal intercourse events, while the females reported use during 58.1% of the events.

At their most recent vaginal intercourse, the proportions were 80% for males and 69% for females, the investigators found.

"We've had a real public health success," Fortenberry told reporters.

In contrast, the lowest rates of condom use were reported by people older than 40, suggesting they "may need better education" about the risks of sexually transmitted infections, Reece told reporters.

The continuing epidemic of such infections -- including HIV -- among black and Hispanic Americans contrasts with the higher rates of condom use reported by those populations, Reece told MedPage Today, and may be a sign that public health messages are beginning to take hold.

But he cautioned that more evaluation will be needed to see if that's the case.

Reece noted that although many of the numbers are encouraging, large gaps remain. "If there's a rate of 40% (for condom use) we in public health may see that as a success," he said, "but that means 60% are not using them."

A striking finding of the study is the disconnect between men and women in terms of pain, pleasure, arousal, and orgasm, Herbenick said.

While most people of either sex found sexual activity arousing and pleasurable, Herbenick said, women tended to have more pain, less pleasure, less arousal, and fewer orgasms. Much of the difference can probably be laid at the door of pain, Herbenick told MedPage Today.

"You would expect that -- if sex hurts, it's not necessarily going to be experienced as pleasurably as it would if it didn't hurt," she said in an interview.

The researchers were not able to tease out the kinds and sources of pain, she said.

The types of sexual activity reported were widely varied, including solo and partnered masturbation, oral sex, vaginal and anal intercourse, and a host of combinations adding up to 41, Herbenick said.

"This is not to say there are only 41," she cautioned," because there are many things we didn't ask about," such as sex toys.

"We really are quite varied and diverse in the ways we express our sexuality," she said.

One clinical implication, she said, is that healthcare providers should be as specific as possible when they ask about sexual behavior of patients.

The studies were supported by Church & Dwight, which makes Trojan brand condoms. Reece said he is a member of the sexual health advisory council of the company. Herbenick and Fortenberry said they had no conflicts.

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